When the Office of Inspector General speaks, it is in your best interest to listen. As you know, modifiers are generally used to provide additional information to the payer about services performed. And the OIG has noted that practices in all specialties, including ophthalmology, are failing to apply modifiers correctly.

OIG Targets –25 and –59

The OIG has identified significant error rates associated with modifiers –25 and –59.

OIG investigations revealed that 35 percent of claims allowed by Medicare with modifier –25 did not meet program requirements. This resulted in $538 million of improper payments. With regard to modifier –59, the OIG found that 40 percent of code pairs billed did not meet program requirements that a service must be demonstratively distinct from the other services performed that day. This resulted in an estimated $59 million of improper payments.

The OIG has recommended that the Centers for Medicare & Medicaid Services and its state contractors seek appropriate documentation for use of these modifiers and conduct prepayment and postpayment reviews to ensure their proper use.

Definitions

Modifier –25Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. This modifier indicates that the identified service is above and beyond the usual preoperative and postoperative care associated with the minor procedure.

Modifier –59Distinct procedural service. This modifier indicates that a hospital or physician performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. This modifier bypasses the Correct Coding Initiative.

5 Tips to Avoid an Audit

To avoid triggering an audit, make sure that your use of modifiers –25 and –59 doesn’t raise any red flags:

–25 should always be appended to the exam code, not the minor procedure code.

–25 should not be appended to the exam code on the same day as the exam and any special testing service(s).

–59 should never be appended to the first of multiple procedures, but to the second and other subsequent procedures.

–59 should only be used when correctly unbundling Correct Coding Initiative (CCI) edits. To find out whether or not unbundling is appropriate, see the current edition of CCI, which can be found under “Coding Tools” at www.aao.org/aaoesite/coding. As an example, it would be incorrect to unbundle CPT code 65775 corneal wedge resection for correction of surgically induced astigmatism with CPT code 66984 cataract extraction with IOL. (Coding for correction of surgically induced astigmatism is never coded at the time of cataract surgery.)

Run a procedure productivity report for the two modifiers. Next, you should conduct an internal chart audit to make sure that you have been applying those modifiers appropriately.

Finally, don’t fall into the trap of assuming that because you’re getting reimbursed, you must be using modifiers appropriately. Unfortunately, the fact that the payer made payment doesn’t mean that it was paid appropriately.